Herniated Disc and Cervical Radiculopathy

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Herniated Disc: A herniated disc occurs when the soft inner gel-like core (nucleus pulposus) of an intervertebral disc protrudes through a tear in the outer fibrous ring (annulus fibrosus), potentially compressing nearby nerves. It is most common in the lumbar spine, particularly at levels L4-L5 and L5-S1.

Cervical Radiculopathy: Cervical radiculopathy refers to the compression or irritation of nerve roots in the cervical spine (neck), often due to a herniated disc, leading to pain, weakness, or numbness in the arm or hand. The most commonly affected levels are C5-C6 and C6-C7.

Aetiology

The primary causes of a herniated disc and cervical radiculopathy include:

• Degenerative disc disease, where the intervertebral discs lose water content and elasticity with age, making them more susceptible to herniation
• Acute trauma, such as lifting heavy objects incorrectly, leading to increased pressure on the discs
• Repetitive strain or movements that put stress on the spine
• Genetic predisposition, as some individuals may have a higher susceptibility to disc herniation

Pathophysiology

The pathophysiology of a herniated disc and cervical radiculopathy involves:

• The nucleus pulposus protruding through a tear in the annulus fibrosus, leading to a herniation
• Compression of adjacent nerve roots by the herniated disc material, resulting in radiculopathy
• Inflammatory responses triggered by the disc material, causing nerve irritation and pain
• In cervical radiculopathy, the compression typically affects the nerve roots exiting the spinal cord at the C5-C6 and C6-C7 levels, leading to radicular pain and neurological symptoms in the upper limbs
• In the lumbar spine, the most common levels of herniation are L4-L5 and L5-S1, which can cause sciatica, or radicular pain radiating down the leg

Risk Factors

• Age-related degeneration, typically affecting individuals between the ages of 30 and 50
• Occupational risks, such as jobs involving heavy lifting, repetitive bending, or prolonged sitting
• Obesity, which increases mechanical stress on the spine
• Smoking, which may reduce disc health by impairing blood flow
• Genetic predisposition, with a family history of disc disease or back problems

Signs and Symptoms

Herniated Disc (Lumbar Spine):

• Lower back pain, often radiating to the buttocks and down one leg (sciatica)
• Numbness or tingling in the leg or foot
• Weakness in the leg or foot, particularly with movements such as lifting the foot (foot drop)
• Reduced range of motion in the lower back
• Exacerbation of pain with activities like bending, lifting, or prolonged sitting

Cervical Radiculopathy:

• Neck pain that may radiate into the shoulder, arm, or hand
• Numbness or tingling in the arm, hand, or fingers, depending on the affected nerve root
• Weakness in the arm or hand, such as difficulty gripping objects
• Reduced range of motion in the neck
• Exacerbation of pain with neck movements, particularly extension or rotation

Investigations

Specific investigations to diagnose a herniated disc and cervical radiculopathy include:

• Magnetic Resonance Imaging (MRI): The gold standard for diagnosing herniated discs and radiculopathy, providing detailed images of the spinal cord, nerve roots, and intervertebral discs.
• X-rays: Used to rule out other causes of symptoms, such as fractures, but are not sufficient to diagnose a herniated disc.
• CT myelography: May be used if MRI is contraindicated, to visualise the spinal canal and nerve roots.
• Electromyography (EMG) and nerve conduction studies: To assess nerve function and differentiate radiculopathy from other causes of nerve pain.
• Neurological examination: Clinical assessment to evaluate muscle strength, reflexes, and sensory function in the affected limbs.

Management

Primary Care Management

• Conservative treatment: Most cases are initially managed conservatively with rest, activity modification, and physical therapy.
• NSAIDs: Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen) for pain relief and inflammation control.
• Physical therapy: To improve strength, flexibility, and posture, with exercises tailored to relieve pressure on the affected nerve.
• Pain management: Analgesics, muscle relaxants, or short courses of oral corticosteroids may be prescribed to manage acute pain.
• Patient education: Advice on posture, lifting techniques, and ergonomic adjustments to reduce strain on the spine.

Specialist Management

• Referral to a spinal specialist: For persistent symptoms despite conservative management or for patients presenting with significant neurological deficits.
• Epidural steroid injections: To reduce inflammation and pain by delivering corticosteroids directly to the affected area around the nerve root.
• Surgical intervention: Considered for patients with severe or persistent symptoms, or in cases of progressive neurological impairment. Common procedures include discectomy, laminectomy, or spinal fusion.
• Ongoing monitoring: Regular follow-up to assess recovery and adjust treatment as needed, with further imaging if symptoms persist or worsen.

References

1. NHS (2024) Herniated Disc. Available at: https://www.nhs.uk/conditions/slipped-disc/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Low Back Pain and Sciatica. Available at: https://cks.nice.org.uk/topics/low-back-pain-sciatica/ (Accessed: 24 June 2024).
3. American Academy of Orthopaedic Surgeons (2024) Herniated Disc and Cervical Radiculopathy. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/herniated-disc/ (Accessed: 24 June 2024).
4. British Medical Journal (2024) Herniated Disc: Clinical Features, Diagnosis, and Management. Available at: https://www.bmj.com/content/350/bmj.h3200 (Accessed: 24 June 2024).
5. National Institute of Neurological Disorders and Stroke (2024) Cervical Radiculopathy Information Page. Available at: https://www.ninds.nih.gov/disorders/all-disorders/cervical-radiculopathy-information-page (Accessed: 24 June 2024).

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